In the series opener of This is Real, we take the listener through one of the biggest health care fraud cases in Washington, D.C., history. Follow Agent Curtis as he goes down one rabbit hole after another to unravel a million-dollar Medicaid fraud scheme orchestrated by a woman who was banned from billing the Medicaid program.
In February of 2014, more than 30 people were arrested in the Nation's Capital on charges related to health care fraud.
Those arrested included owners and operators of home health care agencies, office workers, personal care assistants, and patient recruiters.
Millions of dollars in bank accounts and property were seized, and the bust remains the biggest health care fraud takedown in D.C. history.
You may have heard about the case in the news, but what you didn't get were the stories behind the takedown. You didn't hear about the agents who worked the cases for years, or about the greed of the individuals who stole thousands, and in some cases, millions, from Medicaid, which supports our nation's most vulnerable citizens.
These criminals would never be mistaken for Robin Hood - it's not like they're stealing from the rich to give to the poor. They're stealing from the poor to get rich.
But these agents work tirelessly to track down these fraudsters.
They are law enforcement officials who are on the front lines of our country's battle against fraud, waste, and abuse in federal health care programs such as Medicaid and Medicare.
They work for the Department of Health and Human Services, Office of Inspector General, or "HHS-OIG" for short. But, in this podcast I'm just going to call it "the agency."
In this episode, you'll hear the story of Florence Bikundi and how she ripped off Medicaid for millions.
[Agent Curtis: "What caught my attention the most is that we had a provider - Florence Bikundi - she should have never been involved in the health care system."]
That's Agent Curtis, which by the way isn't his real name. We'll be using pseudonyms for all the agents throughout the series to ensure their identities are protected.
Agent Curtis worked on the case: United States V Florence Bikundi.
Florence Bikundi was the owner of Global Health, which was a large home health care company in Washington, D.C. It employed hundreds of personal care attendants, and they were responsible for the care of thousands of patients, many of whom were Medicaid recipients.
Medicaid provides health coverage if you have a very low income. Medicare, on the other hand, provides health coverage for the elderly or disabled, no matter your income.
Nearly 70 million people are enrolled in Medicaid, which makes it the largest federal health care program. While Medicare is run by the federal government, Medicaid is jointly administered at both the federal and state levels. In 2016 alone, federal and state spending for Medicaid was roughly half-a-trillion dollars.
The agency investigates fraud schemes in both programs, but in this case with Global Health, they were primarily billing Medicaid.
On the outside, Global appeared to be a legitimate company, writing plans of care, obtaining doctor's signatures, and they were billing Medicaid for personal care services.
But on the inside, Global was nothing more than a massive fraud scheme. And it was all orchestrated by a woman who was banned from billing Medicaid.
The agency first learned about the case from the D.C. Department of Healthcare Finance - they run the Medicaid program in the nation's capital.
The tip included three allegations:
First, that Florence Bikundi's company was submitting false documents to Medicaid.
Second, they were billing for services that never occurred.
And third, that Global Healthcare was hiring patient-recruiters. Now, these recruiters were targeting Medicaid beneficiaries to sign up for home health care, even if there was no medical reason for it.
[Curtis: "That's against the rules, you just can't go and knock on people's doors and ask them if they need services. People should go to their doctors first, and then their doctors recommend the services, and that's the appropriate way a home health care relationship should start."]
The beneficiaries were allegedly getting paid by the very same people who were supposed to be providing health services for them: the personal care aides.
[Curtis: "So for not coming to my house, not doing any of the work, the aide gives the patient $100 a week, and you have money then being paid, which is a kickback, from home health care employees to Medicaid recipients for not doing services."]
Agent Curtis was intrigued and dove right into the Bikundi case. But before he could get started he had to find out who this person really was. So he pulled her billing data, he looked at her applications, her paperwork, and any and all documents he could get his hands on to find out more.
[Curtis: "She was very crafty at what she would do in her filling out of documents."]
And what he found was that Bikundi was licensed in different states. Now, that's not uncommon - providers will often service multiple states in the same region.
This is done to ensure they can serve their patients, no matter where they live.
The problem was that Bikundi was using multiple names in her licensing paperwork.
And one of those names, was Florence Igwacho.
Igwacho was Florence Bikundi's maiden name, and in order to make the connection, Agent Curtis did something that you and I do every day.
[Curtis: "I Googled her. You know? Just like everybody else does. And when you Google Florence Bikundi, it comes up with her maiden name, Florence Igwacho, so once I really had her full name I was able to run it on the Exclusion Database and Igwacho did pop up. Florence Igwacho had been previously excluded by HHS-OIG, and Florence Bikundi was that individual - they were one and the same."]
Quick timeout to explain Exclusions. An Exclusion is a legal authority by which the agency can ban an individual or entity from billing Medicare, Medicaid, or any other federal health care program.
Okay, that's a lot of jargon, but this is how it works.
Let's say a doctor's caught diverting drugs for her own use.
The state medical board where she practices can either suspend, or revoke her medical license, which means she can no longer practice medicine in that state.
However, this doesn't necessarily prevent her from practicing medicine in another state, especially if she is already licensed in multiple states.
The agency can exclude her nationwide, meaning she won't receive payments for the care of a Medicare, or Medicaid patient in any state.
In the late 90s, Florence Igwacho was a practicing nurse in Virginia, who was caught abandoning a patient in her care who required around-the-clock attention.
The Virginia Board of Nursing revoked her license in 1999, and the agency excluded her in 2000.
[Music fade out]
[Curtis: "She should have never been involved in the health care system at all, so it intrigued me from that point on - how did this individual get into the system and re-enter the program."]
Ok, let's go through the scheme:
In June 2009, Florence Igwacho registered Global Healthcare with Medicaid using her married name: Florence Bikundi.
Bikundi and her husband then hired office staff, personal care attendants, and patient recruiters to carry out the scheme.
She directed her office staff to create fraudulent patient files and billing information.
The personal care attendants filled out phony time sheets for services that were not fully provided, or were not provided at all.
Lastly, she had patient recruiters target Medicaid beneficiaries and offer cash for their personal health information. That information was then used to bill Medicaid.
The more patients they recruited, the more they could bill.
Over time, Global increased its billing of Medicaid from 1.3 million dollars in 2009 to over $27 million in 2013.
[Todd INT: "…so this was a huge, smooth-running criminal operation going on."
Curtis: "It flows almost like clockwork. Where, you know, they just submit the claims to the District of Columbia for Medicaid. The District of Columbia Medicaid pays them, the money goes into the Global bank accounts, Global cuts checks to all their home health care aides, and then the aides go cash their checks, go to the house, and the aides are paying $150 to the patient. It's great - everybody in the community's happy."]
Not everyone was happy. Hard working D.C. residents, Medicaid recipients who really need care, and of course you and me - the taxpayers - could not be happy about being ripped off by this scheme.
So how'd they steal our money?
Let's do some quick math.
In many cases Global was charging D.C. Medicaid about $16 an hour, 8hrs a day, 7 days a week, for an aide to care for a patient.
That's almost 50,000 dollars a year, per patient. Global had hundreds of aides, many of whom had multiple patients.
[Curtis: "They were able to pay $150 to $200 every two weeks, to a recipient, to a patient out of their paycheck for doing absolutely nothing. That is a kickback, that's against the law, and that is something that our agency goes after, you know, very vigorously."]
If there was so much money flowing out of Medicaid for this one company, how'd they go years before getting caught?
The Centers for Medicare and Medicaid Services, or CMS, they receive billions of claims every day from providers.
Yes - billions of claims.
[Agent Thompson: "You got to understand, they're looking at the claims for every provider. We're talking…millions of providers and billions of claims data that is being processed every single day. So, realistically, it's hard to expect them to find everything.]
That's Agent Thompson. She's an assistant special agent in charge at the agency. You'll be hearing from her a lot during this series.
She's worked extensively with CMS to flag, and prevent fraud that exploits these kinds of gaps in the system.
For example, if the agency identifies a potentially false billing by a provider, it can ask CMS to suspend payments until a more thorough review can be done.
But the challenge with catching a company like Global, is that they know how to bill without raising any red flags.
In fact, for the most part, their claims to Medicaid, which included plans of care, proper codes, and doctors' signatures - they all appeared legitimate.
And remember, those claims aren't just a drop in the bucket. It's more like they're a drop in the ocean of billings that CMS processes every single day - that's the kind of volume we're talking about.
[Agent Thompson: "The data, again, is just the starting point, and even if they were to catch it on that end, that can be just one flag that they're catching…but what else is this doctor doing? You know, what else could they be potentially doing? Just because you stopped that one particular claim from going through. It's definitely better, but, you know, there's still a need for us to be boots on the ground."]
Agent Curtis interviewed dozens of Medicaid beneficiaries and reviewed hundreds of patient files.
He looked at the billing records and diagnosis codes, and what he found was that the number one ailment that Global was billing for, was hypertension.
Now, generally speaking, Medicaid covers different ailments for home health care.
But these services are usually for non-ambulatory Medicaid beneficiaries. So if you break your hip, and you're having trouble moving around, or even getting out of bed, you would likely qualify.
On the other hand, hypertension, or high blood pressure, that was not a qualifying diagnosis for receiving home health care, and yet the claims still slipped through.
Global Healthcare had found a loophole in the system - one that's since been closed up by the way - but nevertheless, they found a way to exploit the system for millions of dollars.
And the fraudulent billing? That wasn't the only scam going on...
[Curtis: "Everybody involved in this scheme, from the lower level home health care aide, all the way up to the top of Florence Bikundi. Everybody in the scheme had a little scam all by themselves."]
Agent Curtis discovered people working as taxi drivers at the same time they were billing as home health care aides.
Other aides were studying to be nurses when they were supposed to be providing care, or they just wouldn't show up at all for their appointments. But they were still billing for care they never provided.
He found that registered nurses were forging documents at the office for a hundred dollars a pop.
[Music fade in]
But one of the most egregious acts of fraud was committed by Florence Bikundi herself.
Say you're a legitimate provider, and you applied for a job at Global.
She wouldn't hire you, but she would keep your application on file.
Then she'd either sell your personal information, or have a relative assume your identity to expand the scheme.
This is Aggravated Identity Theft 1-0-1.
[Music fade out]
As the investigation continued, Agent Curtis uncovered more and more fraud. It seemed like around every corner was another scheme to swindle Medicaid.
[Music fade in]
[Curtis: "It was big. Every door you opened, we call them rabbit holes, every rabbit, every time you find something, it was never-ending with this case. And it was just hole, after hole, after hole."]
Join us in our next episode as Agent Curtis breaks the case wide open and prepares to arrest Bikundi. But with so much money at stake, would she go quietly?
[Curtis: "A search warrant is one of the most dangerous things that we do. If Florence Bikundi or whoever else we're doing a search warrant on, is committing other crimes that we have no idea about? Well, they don't know that we don't know that. They just know the police are knocking at the door - that, that drives people to do things they normally wouldn't do."]
Tune in next time to find out.
Until then I'm Todd Silver. Thanks for listening.
This is Real is produced by the Department of Health and Human Services, Office of Inspector General.
The agency reminds you that if you suspect fraud, waste, or abuse in any HHS programs… including Medicaid or Medicare, report it to our Hotline at 800-447-8477, or 800-HHS-TIPS.
Visit oig.hhs.gov for more information. Follow us on Twitter, like us on Facebook, and watch us on YouTube.